Establishing An Effective Dysphagia Program in a Long Term Care Facility

Kathy Thayer, MA

In the past 20 years, the profession of speech-language pathology has grown to include the treatment of dysphagia in all care settings. The focus of this paper will be the treatment of dysphagia in the long-term care (LTC) setting.

The long-term care setting has changed dramatically in the past 20 years. In the distant past, long-term care settings were reserved for those who were in the end stages of their lives and were not expected to maintain or improve their physical or cognitive levels. The enactment of the Omnibus Reconciliation Act of 1987 resulted in sweeping changes in the nursing home industry by requiring skilled nursing facilities to provide nursing services and specialized rehabilitative services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Since that time, the expectation of state and federal nursing home inspectors is that skilled nursing facilities will make all attempts to improve and/or maintain the quality of lives of their residents and intervene at the first sign of a decline in physical, mental or psychosocial function.

Long-term care survey guidelines mandate that the facility must "maintain acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident's clinical condition demonstrates this is not possible, and receives a therapeutic diet when there is a nutritional problem. The facility must provide each resident with sufficient fluid intake to maintain proper hydration and health.

Eating is, for most people, a pleasurable and social activity as well as a physical necessity. In the long-term care setting, meals present a gathering place for conversation and enjoyment as much a nutritional requirement. Dysphagia affects not only the physical well being of the LTC resident, but also impacts their psychosocial well-being and can lead to a plethora of medical complications including pneumonia, dehydration and malnutrition. Malnutrition has been associated with decreased wound healing, impaired mental functioning and a weakened immune system.

Studies have revealed that the incidence of swallowing disorders in the elderly nursing home population range from 50-75%. Trupe et al [1] studied 140 nursing home residents and found that 74% exhibited some type of eating disorder, 59% of those exhibiting signs of oropharyngeal dysphagia. Siebens et al [2] placed the incidence of dysphagia as high as 66% in the long term care setting. Lin et al [3] investigated 1,221 Taiwanese residents of skilled and intermediate care facilities and found an overall prevalence of 51%.

Westergren et al [4] found that, among 162 residents studied who had suffered cerebral vascular accidents, the incidence of eating disorders was up to 80% with 52.5% of the residents studied unable to feed themselves. In their study, eating difficulties were: 'eats three-quarters or less of served food (60%), difficulties in 'manipulating food on the plate' (56%), 'sitting position' (29%), 'aberrant eating speech' (slow or forced-26%), 'manipulating food in the mouth' (leakage, hoarding, chewing difficulties-24%), 'swallowing difficulties' (18%), 'opening and/or closing the mouth' (16%), and 'alertness' (9%). They also reported 32% of the residents studied were undernourished.